Acute Care exam 3

• PT in the ICU requires specific knowledge of what 5 topics


  - CV/CP physiology and pathophysiology

  - pharmacology

  - multisystem dysfunction

  - medical management

  - ICU equipment

  
  

  *majority of training is mentored on the job
• 4 things that a PT in the ICU must do

  - be a first-rate diagnostician and observer (more co-treatment with other professions)

  - be able to analyze specific O2 transport deficits and problems

  - optimize O2 delivery in pts with critical illness

  - monitor s/sx of activity intolerance (wide variety of pt functional level)
• 8 components of clinical reasoning in the ICU

  - identify correct time to intervene

  - set goals based on pt situation

  - select intervention type

  - set frequency, intensity, duration

  - provide pt education

  - re-assess, modify, or discontinue intervention based on pt response

  - discharge planning (evaluate every time you see the pt)

  - schedule and coordinate care
• How do you know if it is the right time to treat a patient in the ICU?


  assess pt strength, communication, and alertness

  
  

  do not "waste" multiple treatment sessions on low-level intervention (ex. PROM) if you anticipate that the pt will be able to perform more functional activities the next day
• What 2 general goals of PT in the ICU, and how do we achieve them?

  Goal 1 - reduce complications, morbidity, premature morbidity, and length of ICU/hospital stay

  
  

  achieve this by maximizing O2 transport (focus on CP function)

  
  

  Goal 2 - return pt to premorbid functional level OR highest level allowed by their condition

  
  

  achieve this by maximizing MSK and neurological function
• What are the 3 most important things to focus on when mobilizing a PT in the ICU?

  - monitor pt's current medical stability

  - management of lines, tubes, and drains

  - s/sx of treatment intolerance
• 6 s/sx of treatment intolerance that PTs must monitor for in the ICU

  - altered breathing patterns

  - change in cardiac response (BP, HR, heart rhythm)

  - increase in RR

  - change in air blood gas (ABG) (measured from A-line)

  - decreased respiratory tidal volume (measured from a ventilator)

  - change in consciousness (decreased, agitated)
• What might cause a decrease in respiratory tidal volume

  yawn, cough, sneeze

  
  

  OR

  
  

  pt is struggling to breathe
• What are the 8 risk factors for poor outcomes in the ICU?


  - older age

  - comorbidity

  - poor PaO2 with high FIO2 (decreased respiratory function)

  - altered platelet count

  - altered cardiac index (overall health of the heart)

  - altered BUN or creatinine levels (indicates liver or kidney damage)

  - decreased renal function

  - recumbency and restricted mobility (bedrest)
• How do we maximize the function of pts in the ICU?

  the primary goal related to initial function is optimizing CV and pulmonary function

  
  

  focus

  - improve O2 transport

  - optimal function, which includes:

  self-care

  self-positioning

  sitting up

  transfers

  walking

  reduced need for invasive interventions
• 9 general steps of PT care for pts in the ICU


  1. determine pt readiness

  
  

  2. progressive elevation of HOB (legs horizontal --> legs lowered)

  *orientation to gravity, reduce risk of OH

  
  

  3. perform ex while sitting on the edge of bed, feet supported

  
  

  4. transfers --> static standing --> dynamic standing

  
  

  5. steps to bedside chair

  
  

  6. chair exercises

  
  

  7. increased ambulation distance

  
  

  8. increased ambulation independence

  
  

  9. functional activities --> add endurance component
• How do we effectively monitor/assess our chosen interventions for pts in the ICU?


  before txtmnt

  - evaluate indications, precautions, and contraindications for ICU care

  - determine appropriate response to each specific intervention

  - assess need for supplemental O2

  - determine appropriate pt position

  
  

  during AND after txtmnt

  - assess need for supplemental O2

  - determine appropriate pt position

  - evaluate pt response (positive, negative, or no change) to determine where to continue, modify, or discontinue txtmnt
• reflection on action v. reflection in action

  reflection on action - perform txtmnt --> assess --> modify for next time

  
  

  reflection in action - assess txtmnt while performing --> modify in real time
• What are the characteristics of best interventions for pts in the ICU?

  - most efficient

  - have the greatest effect on O2 transport

  - minimize threat to O2 transport

  - maximize benefit-to-risk ratio given specific pt presentation

  - coordinated with other care services
• Level 1 activity in the ICU


  pt supine with HOB elevated

  
  

  goals

  - clinical stability

  - move UEs against gravity

  
  

  interventions

  - PROM TID

  - AAROM

  - turn Q2 hours

  - sitting 20 min TID
• Level 2 activity in the ICU


  pt seated on edge of bed

  
  

  goals

  - sitting upright

  - move LEs against gravity

  
  

  interventions

  - PROM TID

  - AAROM

  - turn Q2 hours

  - sitting 20 min TID

  - sitting on edge of bed
• Level 3 activity in the ICU

  pt seated in chair

  
  

  goals

  - increase strength

  - STS with Min/Mod A

  
  

  interventions

  - AAROM

  - turn Q2 hours

  - sitting 20 mins TID

  - sitting on edge of bed

  - active transfer to chair >20 mins 2x/day
• Level 4 activity in the ICU


  pt up and walking

  
  

  goals

  - increase strength

  - walking a distance

  
  

  interventions

  - AAROM

  - self or assisted turn Q2 hours

  - active transfer to chair >20 min TID

  - ambulation
• mechanical ventilation residual impact

  pt is on a ventilator for a prolonged period of time --> prolonged sedation --> decreased ability to breathe on their own + mental/cognitive decline --> longer hospital stay

  
  

  *PT can improve independent function at time of discharge by 20% (Schweickert, 2009)
• ICU acquired weakness


  critical illness polyneuropathy that affects the limbs (esp LEs) in a symmetric pattern - weakness that is out of proportion for the time spent on bedrest

  
  

  Sx

  - weakness

  - reduced DTRs

  - impaired sensation
• treatment of ICU acquired weaknesss

  - positive end-expiratory pressure (PEEP) *helps pt breathe out

  - pt education

  - ROM

  - functional mobility

  - exercise
• Post-Intensive Care Syndrome (PICS)


  negative impacts on a pt's body, thoughts, feelings, and mind that remain after critical illness and may persist after the pt returns home
• treatment of Post-Intensive Care Syndrome (PICS)


  - talk about familiar things, people and events

  - talk about the day, date, and time

  - family can bring in favorite pictures and items from home

  - read aloud at the bedside

  
  

  **this occurs in both inpatient and outpatient settings
• How to recognize PICS in an outpatient setting

  if a pt is 4-6 weeks out from discharge from the ICU AND are experiencing:

  - memory loss

  - decline in performance
• sara combilizer


  a piece of equipment in the ICU that allows the pt to move from lying, sitting, and standing positions without having to perform transfers

  
  

  benefits

  - useful if pt cannot be safely stood with 2-3 people

  - helps orient the pt to gravity

  - pt completely supported

  - shifts to avoid pressure ulcers

  
  

  use for 5-20 mins

  
• moveo table


  a piece of equipment in the ICU that allows pts to perform CKC exercise while slowly moving towards the against gravity position

  
  

  combines benefits of traditional tilt table standing with active exercise

  
• MOTOmed Upper and Lower Extremity Cycling


  a piece of equipment in the ICU that allows pts to perform cardiovascular training from the hospital bed

  
  

  motor driven, software controlled movement therapy system incorporating a leg cycle or arm/upper body exerciser

  
• integumentary system


  skin, hair, nails

  
  

  largest organ system of the body, receives 1/3 of heart's CO

  
  

  average weight = 8-11 lbs

  
  

  average skin thickness = 0.5-6.0 mm

  
  

  average area = 1.2-2.2 m^2

  
• what are the differences between the following breaks in skin integrity:

  - abrasion

  - laceration

  - ulceration

  - puncture

  - tear

  abrasion - scrape

  
  

  laceration - deep cut

  
  

  ulcerations - blister, open sore

  
  

  puncture - small hole made by sharp object

  
  

  tear - rip
• difference in thickness between epidermis and dermis

  epidermis - 0.06-0.6 mm thick

  
  

  dermis - 2-3 mm thick

  
• 2 layers of the dermis

  papillary dermis - ground substance that conforms to the stratum basale

  
  

  reticular dermis - comprised of dense irregular CT

  
• 5 functions of the dermis


  - supports and nourishes epidermis

  - houses epidermal appendages

  - infection control

  - thermoregulation

  - provides sensation
• What are the 3 layers of subcutaneous tissue?

  - adipose tissue

  - fascia

  - muscle

  
  

  ligament, tendon, and bone are the deepest structures (if a wound reaches this depth --> requires surgical closure)
• What is the response of the dermis to:

  - hot environment

  - cold environment

  too hot --> vasodilation (to release heat)

  
  

  too cold --> cycles of vasoconstriction (to keep heat in) and vasodilation (to keep cells alive)
• 7 functions of the epidermis

  - physical and chemical barrier

  - regulates fluid

  - light touch sensation

  - thermoregulation

  - excretion

  - vitamin D production

  - cosmesis (appearance)
• 4 appendages of the epidermis

  - hair

  - sebaceous glands (secrete oil to maintain skin hydration)

  - sudoriferous glands (sweat glands)

  - nails
• 4 cell types within the epidermis

  - keratinocytes (primary)

  - melanocytes (produce melanin - skin pigmentation)

  - merkel cells (mechanoreceptors)

  - Langerhans' cells (fight infection)
• 5 layers of the epidermis

  - stratum basale (deepest layer, produces new skin cells, damage causes permanent scarring)

  
  

  - stratum spinosum

  
  

  - stratum granulosum

  
  

  - stratum lucidum

  
  

  - stratum corneum (thickest layer, cells are not living)

  
  

  **cells move up through the layers every 14-21 days before sloughing off

  
• Where do blisters occur?

  between epidermis and dermis

  
  

  occurs due to rubbing between dermis and basement membrane of the epidermis
• Define the tissue involvement classifications for wounds:

  - superficial

  - partial-thickness

  - full-thickness

  - deep wound


  superficial - affects epidermis

  
  

  partial-thickness - affects epidermis + part of dermis

  
  

  full-thickness - affects epidermis + dermis + to or into subcutaneous tissue

  
  

  deep wound - involving full muscle or exposing bone/tendon/lig